Common causes for acute jaundice seen in the emergency department include decompensated chronic liver disease, alcoholic or viral hepatitis, and obstructive jaundice due to gallstones or malignancy. Vascular causes (e.g. acute Budd-Chiari syndrome) are rare but can be overlooked. Management is summarized in Figure 23.1.

Make a focused clinical assessment (Table 23.1) and arrange urgent investigation (Table 23.2).

• If the jaundiced patient has signs of sepsis, give IV crystalloid, take blood (and ascitic fluid, if present) for culture, and start empirical IV antibiotic therapy to cover Gram-negative and anaerobic bacteria, in accordance with local guidelines (e.g. piperacillin-tazobactam or meropenem). Further management of sepsis is described in Chapter 35.
• The combination of jaundice and encephalopathy is characteristic of acute liver failure, but is also seen in other disorders (Table 23.3). If you suspect acute liver failure, seek urgent advice from a hepatologist. See Chapter 77 for further management of acute liver failure and decompensated chronic liver disease. Patients with suspected acute liver failure and grade 3 or 4 encephalopathy should be managed in an intensive care unit.
• Jaundice with abdominal pain, distension or tenderness may be seen in a range of medical and surgical disorders (Table 23.4). Obtain an urgent surgical opinion.
• If there is evidence of haemolytic anaemia (anaemia with increased reticulocyte count, abnormal blood film (Chapter 100), elevated plasma lactate dehydrogenase (LDH) and low plasma haptoglobin), seek urgent advice from a haematologist.

Further management is directed by the working diagnosis.

• If ultrasonography demonstrates obstructive (post-hepatic) jaundice, early hepatobiliary intervention is needed: see Chapter 79. Causes of intrahepatic cholestasis are summarized in Table 23.5.
• Patients with presumed viral hepatitis can be discharged home with early clinic follow-up arranged, provided all the following criteria are met:
  • They are clinically stable and not encephalopathic.
  • Paracetamol poisoning, drug toxicity and other disorders which result in high AST/ALT levels have been considered and excluded (Table 23.6).
  • In women of child-bearing age, a pregnancy test is negative.
  • Liver synthetic function is preserved (normal prothrombin time/international normalized ratio and serum albumin).
  • Ultrasonography of the liver and biliary tract is normal.
• If the diagnosis is uncertain, contact your local gastroenterologist or hepatologist for advice.